1. Getting the Vision Right: A multi-disciplinary approach to providing integrated care for respiratory patients Dr Irem Patel, Integrated Consultant Respiratory Physician King’s Health Partners Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

2. The vision For people with respiratory disease in Lambeth and Southwark to experience care that is: High value Consistent Coordinated Supported For healthcare professionals looking after them to have confidence and a clear pathway to deliver care Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

3. COPD: the disease trajectory A story with no beginning…… A middle that is a way of life…… An unpredictable and unanticipated end…… Hilary Pinnock et al, BMJ 2011; 342 Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

4. COPD: organisational factors for improved outcomes Guideline based therapy Regular review – clinical registry Individualised self management Advanced access to knowledgeable HCP Decision support Clinical information systems Improved outcomes Adams et al. Arch Int Med 2007;167:551–6 Steuten et al Int J COPD 2009;4:87–100 Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

5. “ a continuum of patient centred services organised as a care delivery value chain for patients with chronic conditions…… ….optimal daily functioning and health status for the individual…

6. Cochrane Review of Integrated Care for COPD: 2014 26 trials involving 2997 people Mean age 68 years, 68% male, mean FEV1% predicted 44.3% Healthcare settings: primary (n = 8), secondary (n = 12), tertiary care (n = 1), both primary and secondary care (n = 5) Statistically and clinically significant improvement in disease-specific QoL on all domains of the Chronic Respiratory Questionnaire after 12 months Hospitalization days were significantly lower compared with controls after 12 months (MD -3.78 days; 95% CI -5.90 to -1.67, P < 0.001)

7. Context: health care provision in Lambeth and Southwark Page 6 2 teaching hospitals (AHSC) 2 respiratory teams, > 2 consultants One integrated community provider 2 CCGs 2 GP respiratory leads 600,000 population 100 GP practices Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

8. Context: Lambeth and Southwark ‘1 in 5 deaths due to smoking ’ Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

9. Context: COPD mortality in Lambeth and Southwark 4 8 Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

10. A story with no beginning… COPD diagnosis in Lambeth and Southwark LAMBETHSOUTHWARK POPULATION300,000 COPD Prevalence0.88%1.17% TOTAL244832165664 Estimated COPD Prevalence 2.9%3% UNDIAGNOSED561932158834 80678246

11. Harm and waste due to high dose ICS in Lambeth and Southwark 98 practices in Lambeth and Southwark 41 practices agreed 310,775 patients 3537 patients with COPD diagnosis (1.14%) IMD score in most deprived quintile of UK

12. 35% of patients on COPD register did not meet criteria by spirometry

13. Results Spirometry and exacerbation frequency in previous 12 months 38% over treated with ICS 469 patients without spirometry confirmed COPD or asthma = 51% on ICS 12 additional cases of pneumonia per year? Cost: £500,000 per year in L&S

14. The Team Page 13 KCH 8a physio lead GSTT 8a physio lead B7 RNS - ED B7 RNS - AA/ESD/comm B6 physio - AA/ESD/comm B7 RNS - oxygen B7 RNS - wards B6 physio - wards plus community PR team B7 physio – Ambu O2 B7 RNS – Oxygen B7 physio – AA/ESD/comm B6 RNS – AA/ESD/comm B7 physio – PR/wards B6 physio – PR/wards B6 physio - wards Pharmacist Consultant GP Admin 7 day hospital team + 7 day telephone advice line (9-5pm) 7 hospital and community Pulmonary Rehabilitation sites

15. Funding Page 14 DescriptionProviderCost Integrated Respiratory Consultant (5.5 PAs)KHP£58,000 4 x WTE band 7 physiotherapistsKHP (2 on each acute site)£209,076 Pharmacy SupportKHP£8924 Oxygen Administrator (HOSAR service)Surrey Docks Health Centre£30,000 Equipment (LTOT), consumables etcKHP£3,000 TravelKHP£5,000 Education materials/literatureKHP£2,000 1 x 0.1 WTE Primary Care RNSSurrey Docks Health Centre£5,000 Total£321,000

16. Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group High value (“right care”) approaches: COPD value pyramid

17. Optimal Service Model for COPD care in L&S: Tiers of Care TIER 1: Essential Care -Accurate timely diagnosis -Case finding -Disease register -Annual review -Disease specific education -Immunisation -Smoking cessation -Diet and exercise -Responsible resp prescribing -Self management advice -Specialist advice as needed TIER 1: Essential Care -Accurate timely diagnosis -Case finding -Disease register -Annual review -Disease specific education -Immunisation -Smoking cessation -Diet and exercise -Responsible resp prescribing -Self management advice -Specialist advice as needed TIER 2: Enhanced Essential Care -Annual review -Pulmonary rehab -Escalation of therapy -Exacerbations in community -Post exac reviews -Post discharge reviews -Self management plans and rescue Rx -Bone protection -Care Planning -Dietetics -Psychology input -Social input -Case management TIER 2: Enhanced Essential Care -Annual review -Pulmonary rehab -Escalation of therapy -Exacerbations in community -Post exac reviews -Post discharge reviews -Self management plans and rescue Rx -Bone protection -Care Planning -Dietetics -Psychology input -Social input -Case management TIER 3: Specialist Care in Community Admission avoidance Early Supported D/C Oxygen assessment MDT r/v IRT clinics IRT domiciliary r/v Complex psychological input Complex social input Advanced care planning Telephone support Triage referrals (SPR) Education for community HCPS TIER 3: Specialist Care in Community Admission avoidance Early Supported D/C Oxygen assessment MDT r/v IRT clinics IRT domiciliary r/v Complex psychological input Complex social input Advanced care planning Telephone support Triage referrals (SPR) Education for community HCPS TIER 4: Hospital Care Acute admission NIV Complex disease Complex comorbidity Age <50 Rapid deterioration Surgical Rx Lung Transplant VIRTUAL CLINICS

18. Primary prevention Health promotion and education Secondary Prevention: Accurate diagnosis Spirometry screening of high risk patients in community and general practice Accurate performance and interpretation of spirometry (ongoing assessment of competencies with support) COPD register (Ongoing validation with support) Stratification of registers by disease severity: mild, moderate, severe Enhanced referral pathways to specialist support for diagnostic difficulty General Practice Tertiary Prevention: Treatment and management of stable disease Expanded Templates to guide NICE guideline based management Vaccination Named specialist respiratory nurse for practice clusters Specialist medication reviews by community pharmacists Self management education and written individualised action plans Anticipatory care Knowledge and support for carers Enhanced General Practice and community specialist services Complex / severe disease Case management by appropriate case manager (respiratory nurse specialist or Community Matron) Evidence based oxygen prescribing and follow-up Consultant and nurse led clinics with MDT support (including physiotherapy, psychology, dietetics) Non Invasive Ventilation Planned hospital admission for those who need it Specialist and generalist community, hospital and OOH services Unscheduled care Admission avoidance through intermediate care Hospital admission Supported discharge to reduce LOS via EDS programme or intermediate care Post admission review in consultant and nurse led clinics Specialist and generalist community and hospital End of life care Gold Standards Framework Prognostic indicators for primary and secondary care Specialist support Referral pathways Treatment and management Community Pulmonary Rehabilitation Admission avoidance Smoking cessation, health promotion and self care Co-ordinated social care Supportive and palliative care Education and clinical support Information and Clinical Audit Optimal Service Model: COPD Pathway for L&S Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

19. Structured admissions and enhanced recovery: the COPD Discharge Bundle Admission an opportunity for high value interventions Specialist review Structured admission Supported discharge and enhanced recovery CQUIN Integrated approach Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

20. Multidisciplinary integrated care: Supported discharge Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group Team NAMES, email and 7 day telephone no Hospital data READ coded For GP records

21. Multidisciplinary integrated care: Care Planning Page 20 COLLABORATIVE CARE PLANNING Agreed goals with patient to be followed up with GP

22. Responsible Respiratory Prescribing: Virtual Clinics Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group Clinical session, not a meeting Focus on high value care Template to create search patients Link to medicines management Review complex cases Update session Pharmacist support key

23. 94% of practices received VC Evaluation = 4/5 or 5/5 Data from 25 VCs: 372 patients on COPD registers reviewed 321 (86%) patients had their diagnosis of COPD confirmed 279/321 (87%) patients had a recommendation made Recommendations included:  64 (23%) referrals to PR  45 (16%) referrals for smoking cessation support  41 (15%) patients to initiate a LAMA  16 (6%) patients to initiate a LABA  198 (71%) patients to step down/withdraw the ICS Respiratory Virtual Clinics 13/14 to 14/15 Page 22

24. Respiratory Virtual Clinics 13/14 to 14/15 Page 23 4% drop in proportion of ICS prescribing in Lambeth = £50,000 reduction in spend in Q4 and £200,000 savings annually

25. Supporting local respiratory skills: integrated delivery of respiratory education Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group

26. Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group Getting the diagnosis right and getting the right care by the right person at the right time

27. Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group High value approaches – COPD value pyramid

28. Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group Home oxygen assessments and reviews

29. Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group Breathlessness & Cough pathway development

30. IRT Outcomes Increase in COPD prevalence by 11% from 2011/12 to 2014/15 Reduction in COPD admissions by 6%, saving £37,016 and £43,926 per year between 2011/12 and 2013/14 HOSAR service: approximate net savings per quarter of £83,973, ie approximately £503,841 net savings over 18 months for Lambeth and Southwark CCG Respiratory Virtual Clinics: £200,000 savings in inappropriate high dose ICS prescribing to Lambeth CCG Page 29

31. Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group People who make this happen

32. Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group Resources NHSE London Respiratory Strategic Clinical Network http://www.networks.nhs.uk/nhs-networks/london-lungs/ Repository for London Respiratory Team 2010-13 http://www.networks.nhs.uk/nhs-networks/london-respiratory- network/key-documents Impress – Breathlessness, COPD value work & more… http://www.impressresp.com/index.php?view=category&id=11%3Aimpres sions&option=com_content&Itemid=3